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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 65-68

Calcific tendonitis of the gluteus maximus tendon: A case report and review of the literature


Department of Orthopedics, Lilavati Hospital and Research Centre, Bandra West, Mumbai, Maharashtra, India

Date of Web Publication4-Mar-2016

Correspondence Address:
Manoj Kumar
Lilavati Hospital and Research Centre, Bandra West, Mumbai - 400 050, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.178111

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  Abstract 

Calcific tendonitis of gluteus maximus tendon is unusual and only few cases have been reported. A case of calcific tendonitis of gluteus maximus is presented here. A 46 year old female patient with a history of local pain over trochanteric area and radiating along the sciatic nerve. The x-ray showed amorphous calcification around the posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspara. Magnetic resonance imaging confirmed the location of calcification over posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspera with minimal fluid collection deep to tensor fascia lata and in intermuscular plane between gluteus maximus and medius, which is highly suggestive of calcific tendonitis at this unusual location. Ossifying enthesis with well defined cortical defect are frequent at the femoral insertion of the gluteus maximus muscle in asymptomatic subjects which must be differentiated from real cortical lesion sometimes associated with these calcific tendonitis.

Keywords: Calcific tendonitis, gluteus maximus, magnetic resonance imaging


How to cite this article:
Kumar M, D'Silva DF, Shah M, Parekh G. Calcific tendonitis of the gluteus maximus tendon: A case report and review of the literature. J Mahatma Gandhi Inst Med Sci 2016;21:65-8

How to cite this URL:
Kumar M, D'Silva DF, Shah M, Parekh G. Calcific tendonitis of the gluteus maximus tendon: A case report and review of the literature. J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2019 Jul 20];21:65-8. Available from: http://www.jmgims.co.in/text.asp?2016/21/1/65/178111


  Introduction Top


Calcific tendonitis or hydroxyapatite deposition disease is a common disorder and the site of occurrence is around the shoulder mainly within the supraspinatus tendon and at a location 1.5-2 cm away from the tendon insertion on the greater tuberosity. Less common locations include the wrist, elbow, deltoid insertion, gluteus maximus, knee and neck. [1],[2],[3],[4],[5],[6] clinical course and pathological changes of calcific tendinitis are well delineated, but it's cause is unknown. Clinically the syndrome produces local pain and tenderness. Radiographic demonstration of soft tissue calcification is usually diagnostic. The atypical location and presence of bony erosion, marrow changes may result in misdiagnosis of malignancy.


  Case Report Top


A 46-year-old woman presented with local pain over trochanteric area and radiating along the sciatic nerve since 5-6 months. She described the pain as a burning ache mainly at the lateral part of right hip with radiation along the sciatic nerve. The pain worsened with activity, sitting, standing and walking, also she was unable to lie on that hip. Her physical examination was normal, range of movement at hip was normal. Deep palpation over right trochanteric area reproduced her pain symptom.

Laboratory investigation detected no abnormality. A plain radiography of right femur showed amorphous calcification around the posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspara [Figure 1]. Magnetic resonance imaging (MRI) confirmed the location of calcification over posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspara with minimal fluid collection deep to tensor fascia lata and in intermuscular plane between gluteus maximus and medius [Figure 2].
Figure 1: Plain radiography of right proximal femur, antero-posterior and lateral view showing amorphous calcification around the posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspera

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Figure 2: Magnetic resonance imaging showing calcification over the posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspera with minimal fl uid collection

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Macroscopic examination of the material obtained at surgery revealed white, paste-like material within multiple foci in the degenerated tendons [Figure 3]. Microscopic examination revealed the synovial tissue with proliferated and congested vascular channels, focal mild lymphoplasmacytic infiltrates and extensive calcific deposits with few foreign body giant cells surrounding it focally. No granulomas are seen [Figure 4].
Figure 3: Intraoperative pictures showing white, paste-like material within multiple foci in the degenerated tendons

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Figure 4: Microscopic examination showing the synovial tissue with proliferated and congested vascular channels, focal mild lymphoplasmacytic infiltrates and extensive calcific deposits with few foreign body giant cells surrounding it focally

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  Discussion Top


Calcific tendonitis is a common disorder caused by deposition of calcium hydroxyapatite in the periarticular soft tissues, especially the tendon that occurs in as many as 3% of adults. [7] It is the most common form of pathological calcification in the body. The entity has been known by a variety of names: Peritendinitis calcarea, hydroxyapatite rheumatism, calcific periarthritis, or calcific tendonitis. Calcific tendonitis usually has its onset in individuals who are in fourth to sixth decades of age and common in females. 10% of patients affected have bilateral deposits. The most commonly affected sites, in decreasing order of frequency, are the shoulder, hip, elbow, wrist, and knee. [8] The diagnosis of calcific tendonitis accounts for approximately 7% of painful shoulder syndromes. Calcification adjacent to a greater trochanter has been also reported, which is typically located at the insertion of the tendon rather than in the bursae. [9] Calcific tendinitis in atypical locations (one at the insertion of the pectoralis major and five at the insertion of the gluteus maximus) was also reported by Kraemer and El-Khoury. [10] Calcific tendonitis of gluteus maximus is generally located at posterolateral aspect of the proximal femoral shaft, in the vicinity of the linea aspera.

The clinical course and pathological changes of calcific tendonitis are well delineated, but its cause is unknown. Several theories have been proposed including vascular cause, soft tissue/tendon degeneration, critical zone theory, metabolic cause, trauma, soft tissue necrosis and hypoxia-induced metaplasia of the less perfused tendon with resultant calcification. Uhthoff et al. proposed that the initiating event is hypoxia in the "critical area" of the tendon near its insertion. Hypoxia may be followed by fibro-cartilaginous metaplasia of the tendon, with a propensity to calcify. [11],[12] Phagocytosis of calcium and mononuclear cell infiltration appears to follow and may correlate with symptoms. With eventual revascularization, the tendon may be reconstituted, although calcification may persist in asymptomatic individuals for prolonged periods.

Patients may be asymptomatic or present with chronic symptom of pain and disability of varying severity or with acute severe pain and tenderness. In some, the calcium deposits are an incidental finding or are part of an impingement syndrome. Osseous involvement associated with calcific tendonitis has been reported in multiple small series. Calcium hydroxyapatite deposition and resultant inflammatory response in large muscle tendons may produce focal hypervascularity, leading to local bone resorption at the osseous junction. Cortical resorption coupled with large mechanical forces may account for the observed tendency for osseous change at these characteristic sites.

High-quality radiographs are necessary to diagnose calcific tendonitis using imaging. Diagnosis is usually straightforward when the calcific concretions are usually seen at site of insertion of tendons. Hydroxyapatite deposits are homogenous, amorphous densities without trabeculations, which are variable in size and are roughly ovoid but may be linear or triangular. Comet tail appearance of calcification helps to confirm their intratendinous location [13] although this appearance is not invariably present. Ultrasonography is helpful to diagnose more accurately than plane radiography, but there is interpreter variation. Computed tomography (CT) is far superior to plane radiography and ultrasonography for the detection of soft tissue calcification and bony erosion. CT is the optimum modality of imaging to accurately localize the calcific deposit and also depict the continuity of the tendinous, cortical and medullary processes. [14] MRI is not necessary to detect calcifying tendonitis but has an accuracy for detecting calcific tendonitis in more than 95% and is helpful in detecting early tendon and bone marrow changes. In many cases, a firm radiological diagnosis may not be possible and mistakenly diagnosed as malignancy or infection when an in an atypical location.

Nonoperative management is the initial treatment of choice for all patients. Nonoperative treatment usually includes physical therapy, exercises, nonsteroidal anti-inflammatory medications, and steroid injections. The efficacy of any of these treatment methods has not been proved, however Lippmann believed that corticosteroids may abort the resorptive phase, returning the lesion to dormancy and setting into motion the factors necessary for recurrence. Treatment with image-guided (fluoroscopy or CT) injection of a local anesthetic and corticosteroid is successful, and all patients were pain-free on follow-up as reported by Choudur and Munk. [14],[15] More recently, the use of extracorporeal shock wave therapy has been advocated for the treatment of calcific tendonitis. Loew et al. prospectively evaluated 195 patients with chronic calcifying tendonitis treated with extracorporeal shock wave therapy. There was random assignment to control, low-energy, and high-energy groups; high-energy groups received one or two sessions. The results showed energy-dependent success, with relief of pain ranging from 5% in the control group to 58% after two high-energy sessions. Daecke et al. prospectively evaluated 115 patients at 4-year follow-up and found the treatment was successful and without long-term complications for 70% of the patients.

Surgical resection of the concretion has also been used but is not necessary in most cases. Gschwend et al. listed the following as indications for operative treatment:

  1. Symptom progression,
  2. Constant pain that interferes with activities of daily living and
  3. Absence of improvement after conservative therapy.
Patterson et al. reported good results with needling of deposits with repeated perforations to decrease intratendinous pressure. Arthroscopic removal of calcification is another modality of management, which is more common in practice now days.

We emphasize that familiarity with the location of the calcification/enthesis on plain radiographs as well as the appearance of this entity on cross-sectional imaging would result in a firm diagnosis of calcific tendinosis of the gluteus maximus without the need for a biopsy. Further, the pain associated with this entity can be managed appropriately as outlined in the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Faure G, Daculsi G. Calcified tendinitis: A review. Ann Rheum Dis 1983;42 Suppl 1:49-53.  Back to cited text no. 1
    
2.
King JW, Vanderpool DW. Calcific tendonitis of the rectus femoris. Am J Orthop 1967;9:110-1.  Back to cited text no. 2
    
3.
Wepfer JF, Reed JG, Cullen GM, McDevitt WP. Calcific tendinitis of the gluteus maximus tendon (gluteus maximus tendinitis). Skeletal Radiol 1983;9:198-200.  Back to cited text no. 3
    
4.
Berney JW. Calcifying peritendinitis of the gluteus maximus tendon. Radiology 1972;102:517-8.  Back to cited text no. 4
    
5.
Nidecker A, Hartweg H. Rare localizations of calcifying tendopathies. Rofo 1983;139:658-62.  Back to cited text no. 5
    
6.
Hartley J. Acute cervical pain associated with retropharyngeal calcium deposit. A case report. J Bone Joint Surg Am 1964;46:1753-4.  Back to cited text no. 6
    
7.
Bosworth B. Calcium deposits in the shoulder and subacromial bursitis: A survey of 12,122 shoulders. J Am Med Assoc 1941;116:2477-82.  Back to cited text no. 7
    
8.
Gondos B. Observations on periarthritis calcarea. Am J Roentgenol Radium Ther Nucl Med 1957;77:93-108.  Back to cited text no. 8
    
9.
Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: A common clinical problem. Arch Phys Med Rehabil 1986;67:815-7.  Back to cited text no. 9
    
10.
Kraemer EJ, El-Khoury GY. Atypical calcific tendinitis with cortical erosions. Skeletal Radiol 2000;29:690-6.  Back to cited text no. 10
    
11.
Uhthoff HK, Sarkar K, Maynard JA. Calcifying tendinitis: A new concept of its pathogenesis. Clin Orthop Relat Res 1976;164-8.  Back to cited text no. 11
    
12.
Uhthoff HK. Calcifying tendinitis, an active cell-mediated calcification. Virchows Arch A Pathol Anat Histol 1975;366:51-8.  Back to cited text no. 12
    
13.
Seeger LL, Butler DL, Eckardt JJ, Layfield L, Adams JS. Tumoral calcinosis-like lesion of the proximal linea aspera. Skeletal Radiol 1990;19:579-83.  Back to cited text no. 13
    
14.
Thomason HC 3 rd , Bos GD, Renner JB. Calcifying tendinitis of the gluteus maximus. Am J Orthop (Belle Mead NJ) 2001;30:757-8.  Back to cited text no. 14
    
15.
Choudur HN, Munk PL. Image-guided corticosteroid injection of calcific tendonitis of gluteus maximus. J Clin Rheumatol 2006;12:176-8.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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